Consistency in Writing Diagnosis Between Manual Medical Records and E-Puskesmas at the General Polyclinic of Majalengka Community Health Center

Abstract

Inconsistency in writing diagnoses between manual medical records and e-Puskesmas is one of the problems examined in the qualitative analysis of medical records. This has an impact on the quality of medical records and can affect the determination of codification. In addition, diagnostic data is important data. The purpose of this study was to determine the consistency of writing diagnoses in manual medical records and e-Puskesmas for patients at the Majalengka Health Center general polyclinic. This type of research is a quantitative descriptive study. The population in this study was 1894 medical records of patients at the Majalengka Health Center general polyclinic in 2022. The sample used was 400 medical records. The results of the research on the consistency of diagnosis writing between manual medical records and e-Puskesmas showed that 374 diagnoses (93.5%) were consistent and 26 diagnoses (6.5%) were inconsistent. The reasons are: lack of outreach to PPA regarding the importance of writing a diagnosis, the list of abbreviations for diagnosis at the Majalengka Health Center has not been updated, and doctors and nurses have to write a diagnosis twice on the outpatient medical record form and e-Puskesmas. Therefore, officers need to participate in socialization regarding the importance of writing diagnoses, updating the list of abbreviations that apply at the Majalengka Health Center, and re-examining the writing of diagnoses between the outpatient medical record forms and e-Puskesmas